General Psychiatry Flashcards
(192 cards)
1
Q
Which DSM edition was the first to provide explicit inclusion and exclusion criteria, offer extensive information beyond the criteria sets to help clinicians understand the described disorders, and eliminate the term “neurosis”?
A
DSM-III (1980).
2
Q
A 65-year-old man presents with memory problems after a recent stroke in the right hemisphere. What type of deficit would be most expected with a right hemispheric lesion?
A
Visuospatial memory deficits
3
Q
What type of memory deficits are associated with left hemispheric lesions?
A
Verbal memory deficits
4
Q
What labs are followed for carbamazepine treatment?
A
Carbamazepine treatment screening tests initially include a CBC with platelets, liver function tests (LFTs), and BUN/creatinine. Follow-up CBC with platelets, LFTs, and BUN/creatinine are needed once a maintenance dose is achieved. Potassium is not specifically monitored for patients on carbamazepine.
5
Q
What labs are checked on initiation of Lithium?
A
At initiation of treatment, lithium requires laboratory values for sodium, potassium, calcium, phosphate, blood urea nitrogen (BUN), creatinine, thyroid-stimulating hormone (TSH), thyroxine (T4), complete blood count (CBC), urinalysis, beta–human chorionic gonadotropin if appropriate, and an ECG in a
patient older than 40 years or with a preexisting cardiac condition, but LFTs are not required.
6
Q
A 48-year-old British man is admitted to the inpatient unit for progressive cognitive decline and abnormal jerky movements in his left leg over the last 2 months. The clinician suspects Creutzfeldt-Jakob disease (CJD). Which laboratory study could be helpful in confirming the diagnosis?
A
The cerebrospinal fluid 14-3-3 protein is useful for confirmation of CJD in a patient with rapidly progressive dementia and pathognomonic neurological symptoms (i.e., myoclonic jerks).
7
Q
What are the PET and SPECT findings for Alzheimer’s disease?
A
Alzheimer’s disease is often associated with bilateral, symmetric, posterior temporal, and parietal lobe perfusion defects
8
Q
Ainsworth’s seminal “Strange Situation” research on patterns of attachment examined the quality of the mother-child relationship in children of what age?
A
Ainsworth’s seminal research on patterns of attachment examined the secure base behaviors in 12- to 18-month-old children in order to assess the quality of the mother-infant relationship (Ainsworth et al. 1978).
9
Q
At what age do most children begin to develop a gendered sense of self?
A
By around the age of 2 years, most children begin to acquire a gendered sense of self. They accurately label themselves as boy or girl; positive and negative self-feelings accrue to the toddler’s notion of male and female.
10
Q
At what age do children typically develop a theory of mind?
A
The acquisition of a theory of mind, or understanding of mental states, is a transformational process in development, usually demonstrable by the age of 4 years.
11
Q
In the “still-face” experiment, the sudden loss of an affectively reciprocal interaction with the parent would likely cause a healthily attached infant to exhibit what?
A
Acute distress, crying, and averting the gaze.
12
Q
At around what age do children begin to look at and attempt to “read” the facial expressions of others to obtain emotional clues to guide their own behavior?
A
Between 8 and 10 months.
13
Q
In Ainsworth’s “strange situation,” a child with secure attachment would be expected to behave in what way?
A
Secure babies acclimate to the unfamiliar room and explore comfortably while the mother is near, evidence distress during separation, and are comforted by the parent’s return.
14
Q
At around what age do children become able to recognize themselves in a mirror?
A
Age 18 months. Empirically, this major leap of self-awareness is illustrated via mirror self recognition, a clever experiment wherein children are placed in front of a mirror after their noses are surreptitiously rouged; beginning at around 18 months, toddlers tend to smile and attempt to remove the marks from their own noses rather than merely pointing toward their reflections (Lewis and Brooks-Gunn 1979).
15
Q
What is an example of a “negative oedipal complex”?
A
A son longing for his father.
16
Q
What is a predominant defense of the pre-oedipal phase?
A
Pre-oedipal implies poor anxiety tolerance, reliance on splitting as a predominant defense, superego pathology, and impulsivity.
17
Q
A child observes an experiment in which water is poured from a narrow container into one with a much wider shape. In which of Piaget’s phases of cognitive maturation would the child insist that because the second container is wider, it must contain more liquid?
A
Preoperational phase.
18
Q
What is a major developmental goal of adolescence?
A
The search for self-selected “new developmental objects” (i.e., adults available for idealization and identification) is guided in the college or employment setting by the young person’s more conscious and deliberate interests and beliefs: the choice of a mentor facilitates the gradual revision of the superego that is the work of late adolescence. Another task of this period is containment and integration of sexuality to facilitate intimate relationships.
19
Q
In the landmark case Rennie v. Klein (1978), the court recognized the right of psychiatric patients to refuse treatment but concluded that this right could be overridden in which of the following circumstances?
A
The patient is a danger to himself or others.
20
Q
If a patient commits suicide, what circumstances renders the psychiatrist most vulnerable to a wrongful death claim?
A
Psychiatrists are not automatically liable whenever an outpatient commits suicide (Speer v. United States 1981). Instead, the reasonableness of the psychiatrist’s efforts is determinative. A failure either to reasonably assess a patient’s suicide risk or to implement an appropriate precautionary plan after the suicide potential becomes foreseeable is likely to render a practitioner liable if the patient is harmed because of a suicide attempt.
21
Q
A psychiatrist is most likely to be sued successfully when a patient commits suicide in which clinical setting?
A
Psychiatrists are more likely to be sued successfully when a psychiatric inpatient commits suicide. The law permits the fact finder to conclude that the opportunities to foresee (i.e., anticipate) and control (i.e., treat and manage) suicidal patients are greater in the hospital (Hofflander v. St. Catherine’s Hospital 2003).
22
Q
A managed care company refuses to authorize payment for an extended hospital stay for a patient who is deemed violent by the hospital’s doctors. Which entity is most likely to carry the burden of liability if this patient commits a violent act soon after discharge?
A
The inpatient psychiatrist.
23
Q
Describe the guidelines for therapeutic boundaries in psychiatry.
A
Therapeutic boundaries are important in any type of clinical work, but they are especially important in the intimacy of the psychotherapeutic relationship. Such boundaries include temporal and spatial limits: therapeutic encounters typically occur at the physician’s office during business hours, except in crisis situations. Limits are also observed in the nature of the relationship, which involves the psychiatrist being paid for services and acting as a fiduciary, a professional who is worthy of the patient’s trust. Nontherapeutic encounters, including business arrangements, social relationships, and sexual activity, are forbidden. Within the therapeutic relationship, limits are also observed. The patient is encouraged to share intimate feelings, thoughts, and memories, whereas the physician generally avoids self disclosure and adopts a posture of neutrality. Physical contact other than handshakes is avoided.
24
Q
Serious boundary violations such as sexual contact with patients are associated with which physician risk factors?
A
Inadequate training, isolation from colleagues, and narcissistic pathology.
25
When considering the diagnosis of speech sound disorder, it is important to know that the speech of a young child should be fully intelligible by the age of ___, and full mastery of speech sounds of one’s native language should occur by the age of ___.
Full mastery of the speech sounds of one’s native language should occur by age 8 years; however, the speech of a young child should be fully intelligible by age 4 years.
26
A 10-year-old girl with a seizure disorder has an IQ of 50, becomes agitated by bright light, and has limited interest in social interaction. What is the most likely diagnosis?
Autism spectrum disorder.
27
A 6-year-old girl is noted to have poor motor coordination for her age. She often bumps into objects and is unable to catch a ball. Although her mother works with her, practicing skills, her play is significantly impacted. These symptoms seemed to have started before the age of 3. What is the most likely diagnosis?
Developmental coordination disorder.
28
According to DSM-5, by what age must symptoms be present for a child to be diagnosed with attention-deficit/hyperactivity disorder (ADHD)?
Age 12 years.
29
What fraction of children with ADHD can be expected to no longer exhibit symptoms in adulthood?
Roughly one-third of individuals appear to no longer exhibit symptoms of ADHD during adulthood.
30
What is considered the “gold standard” diagnostic tool for direct assessment of symptoms of autism spectrum disorders (ASD)?
Autism Diagnostic Observation Scale.
31
A patient with chronic schizophrenia has had five hospitalizations and three additional emergency room visits over the past year, mostly in the context of treatment nonadherence. She has a history of multiple medical problems requiring treatment by various specialty providers and has experienced difficulty in maintaining housing. Which of the treatment modalities is most appropriately suited to this patient?
Assertive community treatment
32
What has been found in neuroimaging studies of patients with schizophrenia?
The most reproducible findings are a slight overall decrease in brain volume and an increase in size of ventricles. Localized findings are less reproducible, but among the most robust are decreased size of the hippocampus, superior temporal lobe, prefrontal cortex, and thalamus. Many of these deficits are present at first psychotic break and in nonaffected relatives with high genetic risk for schizophrenia, suggesting that they contribute to susceptibility to disease rather than result from disease and treatment (Fornito et al. 2009; Vita et al. 2006).
33
A 19-year-old patient begins treatment following his first episode of psychosis. His parents ask about their son’s long-term prognosis. Which of the following prognostic statements about this patient would be most accurate?
One in five patients achieves sustained recovery. Ultimately, about one-third of patients achieve a relatively good outcome with only mild symptoms and functional impairments, with the remainder having moderate to severe symptoms and functional impairments.
34
According to historical evidence from before the antipsychotic era, which positive symptom is most common among individuals with schizophrenia?
```
Historical evidence (from before the antipsychotic era)
shows that 91% of hospitalized patients had delusions (47% marked/severe), 87% had bizarre behavior (40% marked/severe), 66% had hallucinations (28% marked/severe), and 66% had thought disorder (8% marked/severe) (Fenton and McGlashan 1991).
```
35
What are risk factors for suicide among patients with schizophrenia?
Risk factors for suicide among people with schizophrenia include younger age, younger age at symptom onset, high premorbid functioning,high personal expectations, awareness that life’s expectations are unlikely to be met, awareness of symptoms (especially if aware of delusions, anhedonia, asociality, blunted affect), and a negative attitude toward or noncompliance with treatment.
36
Describe the stages of schizophrenia over the lifespan.
Premorbid, prodromal, progressive, and chronic-residual
stages. The progressive stage of schizophrenia can be said to begin when overt psychotic symptoms develop. Five to 10 years after entering the progressive stage of schizophrenia, patients typically enter what may be called the chronic-residual stage, which is characterized not by inexorable progression but rather by the persistence of residual symptoms and disability.
37
What is the relationship between primary and secondary negative symptoms in schizophrenia?
Secondary negative symptoms are caused by positive
symptoms. For example, a person who is socially withdrawn due to paranoia might increase social activities when less paranoid.
38
What nongenetic risk factor for developing schizophrenia has the highest OR?
Chronic psychostimulant use (OR=10) (MacDonald and Schulz 2009).
39
In what gender is Bipolar II disorder more common?
Women
40
Rank three mood stabilizers in highest to lowest propensity for weight gain?
Valproate > lithium > lamotrigine
41
What is the most common side effect of aripiprazole in adults?
Akathisia.
42
What would be the most likely diagnosis for a child presenting with persistent, chronic irritability and frequent episodes of extreme behavioral dyscontrol?
Disruptive mood dysregulation disorder (DMDD).
43
A 6-year-old girl with a chronic negative mood and frequent and severe verbal and behavioral outbursts in response to common stressors is most likely to go on to develop which disorder in adulthood?
Major depressive disorder.
44
What symptoms are less commonly associated with bereavement and can indicate a major depressive episode even in light of a significant loss?
feelings of worthlessness, suicidal ideation (distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment in overall functioning
45
What diagnoses cannot co-exist with DMDD, according to Criterion J?
oppositional defiant disorder, IED, or bipolar disorder
46
What are atypical features of depression?
Hypersomnia is considered to be an atypical feature of depression, as is increased appetite, a heightened sensitivity to interpersonal rejection, and leaden paralysis. Mood reactivity, such as mood brightening in response to positive events, is also considered to be an atypical feature of depression.
47
What would be the most appropriate diagnosis for a child who has frequent temper outbursts but no evidence of persistent mood disruption between outbursts?
Intermittent explosive disorder (IED).
48
What is the lifetime prevalence of panic disorder in the U.S. general population?
3.8%.
49
What is the lifetime comorbidity of anxiety disorders with other mental disorders among adults in the U.S. population?
90%
50
According to twin studies, what is the estimated heritability of panic disorder?
40%.
51
Which brain structure is involved in the intense somatic sensations experienced by patients with panic disorder?
Insula.
52
What is the minimum duration of symptom persistence required for a diagnosis of generalized anxiety disorder (GAD)?
Six months.
53
What is an exposure technique used in the treatment of panic disorder?
Hyperventilation.
54
What is the best-established pharmacotherapy for treatment of specific phobia?
Benzodiazepines.
55
The efficacy of buspirone in the treatment of anxiety disorders is limited to which disorder?
Generalized anxiety disorder.
56
Which of the anxiety disorders has the youngest median age at onset?
Among the anxiety disorders, social anxiety disorder (social phobia) has the youngest median age at onset, at 15 years.
57
Which of the anxiety disorders has the lowest lifetime prevalence?
Among the anxiety disorders, agoraphobia has the lowest lifetime prevalence, at 2.5%.
58
Onset of worry, nervousness, tearfulness, and suicidal ideation in a previously healthy person most likely represents what?
Major depressive disorder (MDD).
59
Which of the anxiety disorders has the oldest median age at onset?
Among the anxiety disorders, generalized anxiety disorder has the oldest median age at onset, 30 years.
60
Behavioral treatment for obsessive-compulsive disorder (OCD) typically includes what?
Exposure and response prevention
61
Shortly after becoming ill with a respiratory infection, a 10-year-old boy begins to display symptoms of checking. What organism is most likely to be responsible for his infection and psychiatric symptoms?
Group A beta-hemolytic streptococcus (Streptococcus pyogenes). In PANS, children affected by streptococcus may exhibit obsessive compulsive and related symptoms that sometimes (but not always) resolve after effective treatment of the streptococcal infection. Studies have found that the basal ganglia must be affected by the infection in order for PANS to occur.
62
What is the approximate lifetime prevalence of obsessive-compulsive disorder (OCD) in the U.S. general population?
2.5%.
63
List some common compulsive behaviors.
Common compulsive behaviors include excessive
| cleaning (e.g., hand washing), checking, ordering, rearranging, counting, repeating, and mental rituals.
64
Among individuals with obsessive-compulsive disorder (OCD), what is the most common comorbid psychiatric diagnosis?
Major depressive disorder.
65
What is the concordance rate of obsessive-compulsive disorder (OCD) in monozygotic twins?
A review of twin studies found that there is a strong heritable component to OCD, with concordance rates of 80–87% in monozygotic twins compared with 47%–50% in dizygotic twins (van Grootheest et al. 2005).
66
What neuroanatomical mechanisms is posited to be involved in the pathophysiology of obsessive-compulsive disorder (OCD)?
Hyperactivity in the ventral cognitive loop (orbitofrontal
| cortex, caudate nucleus, dorsomedial thalamus).
67
People with body dysmorphic disorder (BDD) often seek care from practitioners of what medical specialty?
Many will seek care from dermatologists and/or cosmetic surgeons.
68
Findings from studies examining psychiatric comorbidity in individuals with body dysmorphic disorder (BDD) show that approximately what percentage will experience obsessive-compulsive disorder (OCD) at some point in life?
33%.
69
What is the most common psychiatric comorbidity with body dysmorphic disorder?
Major depressive disorder, with a lifetime prevalence of 75%, is the most common comorbid diagnosis.
70
Which psychotropic medication class can cause substance-induced obsessive-compulsive and related symptoms?
Atypical antipsychotics. The substances most commonly
reported as potentially causing obsessive-compulsive and related symptoms are the stimulants (including amphetamines and cocaine).
71
What is the first-line therapy for hoarding disorder?
Behavioral therapy is considered the first-line treatment
| for hoarding disorder.
72
In which gender is skin picking disorder more prevalent?
Women
73
In a child with reactive attachment disorder (RAD), which area is least likely to improve with treatment?
Social development
74
What is the most replicated functional neuroimaging abnormality in posttraumatic stress disorder (PTSD)?
Hyporesponsivity of ventromedial prefrontal cortex.
75
What is the earliest developmental age at which reactive attachment disorder (RAD) may be diagnosed?
9 months
76
What is the only class of medication shown to be effective in reducing the full range of posttraumatic stress disorder (PTSD) symptoms?
Selective serotonin reuptake inhibitors (SSRIs).
77
Which population has its own subtype of posttraumatic stress disorder (PTSD) in DSM-5?
Preschool children
78
Which widely used medication class may interfere with extinction learning and increase the risk of posttraumatic stress disorder (PTSD) after a traumatic event?
Benzodiazepines.
79
According to the American Academy of Child and Adolescent Psychiatry (AACAP), what initial treatment is recommended for children with posttraumatic stress disorder (PTSD)?
Trauma-focused cognitive-behavioral therapy (CBT).
80
To qualify for a DSM-5 diagnosis of adjustment disorder, symptoms must occur within what period following onset of a stressor and must resolve within what period following removal of the stressor?
Symptom occurrence within 3 months of stressor’s onset and symptom resolution within 12 months of stressor’s removal.
81
What is the most prominent focus of prolonged exposure therapy for the treatment of posttraumatic stress disorder (PTSD)?
Repeated imaginal and in vivo exposures to enhance extinction of traumatic memories and decrease cue reactivity.
82
What is the essential feature of reactive attachment disorder (RAD)?
Absent attachment between child and putative caregiving adults.
83
A 6-year-old child exhibits overly familiar behavior, often crossing boundaries, with no reticence to approach strangers and minimal hesitation in going off with unfamiliar adults. There is a history of consistent parenting since birth. Which of the following diagnoses is most likely?
Disinhibited social engagement disorder.
84
To qualify for a DSM-5 diagnosis of acute stress disorder, symptoms must persist for what duration after a traumatic event?
At least 3 days to 1 month.
85
Which early intervention strategy in trauma survivors can actually increase stress and posttraumatic stress disorder (PTSD) symptoms?
Conducting a debriefing focused on the traumatic experience
86
In studies examining biological responses to trauma-related stimuli in subjects with posttraumatic stress disorder (PTSD), which finding has been repeatedly confirmed?
One of the earliest and best replicated PTSD findings is heightened autonomic (heart rate, skin conductance) and facial electromyographic reactivity to external, trauma-related stimuli, such as combat sounds and film clips, as well as to internal, mental imagery of the traumatic event.
87
What change in sleep architecture has been demonstrated in individuals with posttraumatic stress disorder (PTSD)?
More Stage 1 sleep and less slow-wave sleep, indicative of shallower sleeping, have been demonstrated in patients with PTSD (Kobayashi et al. 2007).
88
What best characterizes the quality of peer relationships among adolescents with disinhibited social engagement disorder (DSED)?
Superficial.
89
What condition is characterized by an inability to recall important personal information (including traumatic memories) that cannot be explained by ordinary forgetfulness, overt brain pathology, or substance use?
Dissociative amnesia
90
What condition is characterized by persistent feelings of
| unreality, detachment, or estrangement from oneself?
Depersonalization/derealization disorder.
91
The overall disturbance in dissociative disorders involves what?
A failure in integration of experience.
92
Recall of a personal experience identified with the self, such as attending a basketball game, involves which type of memory?
Episodic memory.
93
What neuroanatomical locations are associated with semantic memory?
Explicit (or episodic) memory involves recall of personal experience identified with the self (e.g., “I was at the ball game last week”). Implicit (or semantic) memory involves the execution of routine operations, such as riding a bicycle or typing. These two types of memory have different neuroanatomical localizations: the limbic system, especially the hippocampal formation, and mammillary bodies for episodic memory, and the basal ganglia and cortex for semantic memory (Mishkin and Appenzeller 1987).
94
What pattern characterizes the nature of memory
| loss in dissociative amnesia?
The memory loss is generally for traumatic or stressful events.
95
What is the difference between dissociative amnesia and repression?
The organizational structure of mental contents in dissociation is considered to be horizontal, with subunits of information divided from one another but equally available to consciousness (Hilgard 1977). Repressed information, on the other hand, is presumed to be stored in an archaeological manner, at various depths, and therefore different components are not equally accessible (Freud 1923/1961).
96
Experiencing of others as unreal, dreamlike, or foggy is an example of what?
Derealization.
97
Which of the dissociative disorders is considered to be the most common?
Dissociative amnesia.
98
What is a key feature of illness anxiety disorder?
A key feature is that there are no significant somatic symptoms present, and a predominant response to the preoccupation is anxiety.
99
After ruling out a medical illness, how should treatment of factitious disorder be approached?
The physician should inform the patient of a treatment plan and attempt to enlist him or her in that plan, with minimal expectation that the patient will “confess” to the deception.
100
What metabolic abnormalities may be expected with self-induced vomiting in bulimia nervosa?
dehydration, hypochloremia, hypokalemia, and metabolic alkalosis
101
Which of the anxiety disorders is more common among patients with the binge-eating/purging subtype of anorexia nervosa than among those with the restricting subtype?
Posttraumatic stress disorder seems to cluster primarily in those with the binge eating/purging subtype, who have a higher rate of prior exposure to traumatic stress.
102
Which psychiatric disorder is most commonly seen in patients with binge-eating disorder?
Major depressive disorder.
103
What is the most effective treatment for osteopenia and osteoporosis in patients with anorexia nervosa?
Weight gain.
104
What fluid/electrolyte abnormality is associated with the refeeding syndrome in anorexic patients?
Hypophosphatemia and hypomagnesemia are particularly problematic in low-weight patients early in the course of refeeding.
105
Which compensatory behavior is most commonly used by patients with bulimia nervosa?
self-induced vomiting, which occurs in about 90% of patients
106
What is the only drug currently U.S. Food and Drug Administration (FDA) approved for bulimia nervosa?
Fluoxetine.
107
Which DSM-5 diagnostic criterion differentiates bulimia nervosa from binge-eating disorder?
Recurrent inappropriate compensatory behavior aimed at preventing weight gain.
108
What is the most commonly abused substance among patients with binge-eating disorder?
Alcohol.
109
Which area of the brain appears to be linked to the behavioral disinhibition seen in patients with binge-eating disorder?
Prefrontal cortex.
110
Which type of intervention has been shown to be most efficacious in reducing frequency of binge episodes in binge-eating disorder?
Psychotherapeutic or behavior therapy approaches. There is also evidence that weight loss strategies can reduce binge eating, at least in the short run.
111
The term secondary enuresis refers to what?
Incontinence that follows a period of sustained continence.
112
What is a risk factor for primary nocturnal enuresis?
Family history of PNE.
113
How does secondary enuresis differ from primary enuresis in terms of treatment?
Individuals with secondary enuresis are more likely to benefit from psychotherapy.
114
What is the gender prevalence of enuresis?
Enuresis is approximately twice as common in boys as in girls.
115
Enuresis is most commonly comorbid with what psychiatric condition?
Attention-deficit/hyperactivity disorder.
116
What is the course and prognosis of primary nocturnal enuresis (PNE)?
PNE is a self-limiting disorder that will eventually spontaneously remit.
117
What is the advantage of the "bell and pad" treatment of PNE over pharmacotherapy?
The therapeutic effect is usually sustained after the cessation of treatment, whereas remission almost always occurs after the cessation of treatment with imipramine or desmopressin (Kwak et al. 2010).
118
What best characterizes the electroencephalogram (EEG) tracing of rapid eye movement (REM) sleep?
Low-voltage fast activity.
119
What is the prevalence of insomnia symptoms in the U.S. population?
Up to 33%.
120
What is the normal muscle response during REM sleep?
paralysis
121
What symptom is characteristic of patients with non–rapid eye movement (NREM) sleep arousal disorder?
Total or partial amnesia for nighttime events.
122
What is the metabolic effect of a single night of partial sleep deprivation?
Partial sleep deprivation during a single night induces insulin resistance. Difficulty falling asleep, unrefreshing sleep, and particularly loud snoring predicted the development of metabolic syndrome in community-living adults (Troxel et al. 2010).
123
Which of the commonly prescribed hypnotic medications is a melatonin agonist?
Ramelteon.
124
A score of 0–2 on the Epworth Sleepiness Scale is most likely to indicate what?
Hyperarousal secondary to depression or anxiety
125
Dysregulation of circadian rhythm can be treated with what?
Use of exogenous melatonin.
126
Describe the 4-step sleep evaluation.
1. Identify the complaint.
2. Clarify the complaint—Is the patient fatigued or truly sleepy?
3. Evaluate sleep habits and sleep environment—Does poor sleep hygiene
contribute to the patient’s sleep problems?
4a. Screen for common sleep disorders:
A. Sleep phase delay (“night owl” syndrome)
B. Obstructive sleep apnea
C. Insomnia disorder
D. Restless legs syndrome
4b.Consider the possible presence of other sleep disorders:
A. Non–rapid eye movement (REM) sleep arousal disorders (e.g., sleepwalking,
sleep terror)
B. REM sleep behavior disorder
C. Narcolepsy
127
Sleep-related eating is considered to be a specialized form of what?
Sleepwalking.
128
What lab should be checked in all patients with restless leg symptoms?
For all patients with restless legs syndrome (RLS), the clinician should obtain a serum ferritin level, which provides a measure of body iron stores. Iron needs to be replaced if levels are 50 ng/mL or less (although 50 will be reported as “normal” by laboratories).
129
What is the difference between excessive daytime sleepiness and fatigue?
“Sleepiness” is a common complaint of patients who cannot stay awake but also of those who cannot sleep when given the chance. The former is true sleepiness (EDS); the latter is fatigue due to physiological hyperarousal, which is often accompanied by lack of energy, motivation, and mental clarity.
130
What percentage of patients with obstructive sleep apnea may have normal Epworth scores?
30%
131
Circadian rhythms are controlled by what brain structure?
Suprachiasmatic nucleus
132
Describe Process S and Process C.
Borbely and Achermann (1999) have postulated a clinically useful two-process model for sleep and sleep regulation: Process S is the Sleep homeostatic drive, which increases in strength as a function of time awake. The opposing Process C is the Circadian arousal drive, which increases during the day, thus maintaining the state of wakefulness and preventing Process S from taking over until the normal bedtime approaches, at which point the Process C arousal drive begins to diminish and Process S is permitted to take over.
133
What is a treatment approach with proven efficacy for early ejaculation?
Pharmacological treatment with selective serotonin reuptake inhibitors (SSRIs). Paroxetine, an SSRI with the strongest delay of ejaculation among the SSRIs, is commonly employed.
134
A 22-year-old man is diagnosed with schizophrenia and started on risperidone 3 mg twice a day. After 2 weeks, he reports clear thinking and cessation of auditory hallucinations; however, he is bothered by the fact that his ejaculation is delayed. What is the best first course of action in this case?
Lower the dose of risperidone.
135
Which medication class is contraindicated in combination with a phosphodiesterase type 5 (PDE-5) inhibitor?
Nitrates.
136
Describe the typical biological process of erection in men?
Stimulation (visual, etc.) releases nitric oxide in the corpora cavernosa. Nitric oxide activates guanylate cyclase, leading to increased production of cyclic guanosine monophosphate (cGMP). The cGMP relaxes the smooth musculature of the corpora cavernosa and thus facilitates the blood inflow into them. Increased blood inflow into the corpora cavernosa leads to their distention, which finally produces erection.
137
All but one of the DSM-5 sexual dysfunctions require a symptom duration of at least 6 months and presence of symptoms on at least 75% of occasions of sexual activity. Which sexual dysfunction does not include these requirements?
Substance/medication-induced sexual dysfunction.
138
In a 50-year-old obese man who smokes and presents with erectile dysfunction, which clinical test would you prioritize?
A lipid panel.
139
Genito-pelvic pain/penetration disorder (GPPPD) in DSM-5 is a new diagnostic entity taking the place of which two disorders described in DSM-IV-TR?
Dyspareunia and vaginismus.
140
How is the diagnosis of substance/medication-induced sexual dysfunction (SMISD) usually made?
By noting a close temporal relationship between the initiation of a medication or dose increase and the occurrence of the sexual problem.
141
What is the cornerstone in treatment of genito-pelvic pain/penetration disorder?
Multidisciplinary evaluation.
142
Which disorder category is often associated with gender dysphoria in childhood?
Anxiety disorders.
143
What is the beginning phase of the treatment of adult gender dysphoria?
Encouraging the patient to live in the world in the cross-gender role.
144
What is a relatively common side effect of hormone therapy during sex reassignment in men?
Depression.
145
What neurotransmitter is most commonly associated with impulsive aggression?
Serotonin.
146
What would be the recommended treatment approach for an adolescent boy with oppositional defiant disorder (ODD)?
Cognitive-based techniques.
147
What is new in the DSM-5 diagnosis of oppositional defiant disorder (ODD)?
DSM-5 (American Psychiatric Association 2013) now categorizes ODD symptoms based on whether they have an emotional component (e.g., angry, irritable, resentful), a behavioral element (e.g., argumentative, defiant), or a spiteful/vindictive aspect to them.
148
Kleptomania is most often associated with which two personality disorders?
Paranoid and histrionic personality disorders.
149
What disorder is most commonly comorbid with oppositional defiant disorder (ODD)?
Attention-deficit/hyperactivity disorder (ADHD).
150
The mother of a 7-year-old boy reports that for the past 8 months, her son fights almost daily with her and with his teachers, always questions the rules, and provokes his sister and his classmates. As a result of this behavior, the boy is doing poorly in school and has no friends. When you talk to the boy, it is apparent that he believes his actions toward others are justified because they are “mean” to him. He has not gotten into any physical fights. Which of the following is the most likely diagnosis?
Oppositional defiant disorder.
151
Presence of oppositional defiant disorder (ODD) with emotional symptoms predicts future development of what?
Anxiety disorders.
152
A 21-year-old man with a history of oppositional defiant disorder presents with frequent impulsive behavioral outbursts that are grossly out of proportion to the stressor. He reports that he is unable to control himself and is worried that he might lose his job if his behavior continues. What is the most likely diagnosis?
Intermittent explosive disorder (IED).
153
What is the defining feature of kleptomania?
The inability to resist repetitive urges to steal specific items that are not required for personal function or utility or for their monetary worth.
154
Presence of oppositional defiant disorder (ODD) with spiteful/vindictive symptoms predicts future development of what?
Conduct disorder.
155
What medication has been shown to be more effective for aggression in patients with Cluster B personality disorders than in patients with intermittent explosive disorder (IED)?
Divalproex.
156
Compared with females, males with conduct disorder (CD) demonstrate what?
A more linear year-to-year increase in prevalence. The childhood-onset subtype demonstrates a considerable male predominance and may be predictive of more numerous and severe symptoms. The prevalence of CD increases with age and levels off at approximately 15–16 years, with males showing a more linear year-to-year increase than females, who demonstrate a greater increase starting mostly in adolescence (Maughan et al. 2004).
157
Pyromania most often begins during which life phase?
Early adulthood.
158
What is characteristic of pyromania?
Fascination with fire.
159
What percentage of children with CD develop antisocial personality disorder as adults?
Estimates suggest that up to 40% of children diagnosed with CD develop antisocial personality disorder as adults, especially children who use substances before age 15 years, children living in severe poverty, and children placed in foster care or other out-of-home placement (Robins and Ratcliff 1979).
160
The “with limited prosocial emotions” specifier for conduct disorder (CD) is associated with what?
Less responsiveness to behavioral treatment. Multiple sources of information (e.g., self-report, as well as reports from family members, teachers, and/or peers who have observed the child’s behavior for an extended period of time) should be considered to determine the persistent presence of these traits.
161
What percentage of individuals with alcohol use disorder undergoing severe withdrawal exhibit seizures that require emergent hospital care?
Less than 5%.
162
What are two lab tests that, when combined, have a sensitivity of 90% in detecting alcohol use disorder?
Gamma-glutamyltransferase (GGT) and carbohydrate-deficient transferrin (CDT).
163
What antidepressant is a U.S. Food and Drug Administration (FDA) approved pharmacotherapy for smoking cessation?
Bupropion.
164
What is a common side effect of varenicline?
Nausea.
165
What medication has as its mechanism of action the inhibition of aldehyde dehydrogenase?
Disulfiram.
166
What medical complication of alcohol use disorder is more common in women?
The association of heavy alcohol use with death from hepatocellular carcinoma is greater for women than for men.
167
What is the primary mechanism of action of opiates?
Dopamine release by disinhibition of inhibitory GABAergic neurons through mu receptor agonism.
168
What is the neuroanatomical location of the opioid receptors that cause respiratory depression?
Locus coeruleus
169
What is the gender prevalence of tobacco use disorders?
In 2010, current use of a tobacco product among persons ages 12 and older was reported by a higher percentage of males (33.7%) than females (21.5%).
170
What is thought to be the mechanism of action of hallucinogens such as lysergic acid diethylamide (LSD)?
Agonism of serotonergic 5-HT2A receptor.
171
What laboratory results would be suggestive of Wilson’s disease?
Low blood ceruloplasmin and high urinary copper.
172
What cerebrospinal fluid (CSF) findings would you expect in Alzheimer’s disease?
Low beta-amyloid 42 and high tau and phosphorylated tau.
173
Which neurocognitive disorder is associated with rapid eye movement (REM) sleep behavior disorder?
Lewy body disease.
174
What is a functional brain imaging finding in Lewy body disease?
Functional brain imaging frequently shows low blood flow or low metabolic activity in the occipital lobes.
175
What is the prototypical behavioral variant of frontotemporal lobar degeneration (FTLD)?
The prototypical behavioral variant of FTLD is caused by Pick’s disease and presents as personality change with progressive impairment of judgment, loss of social graces, disinhibition, stimulus boundedness, and a craving for sweets.
176
Describe the onset and progression of frontotemporal lobar degeneration.
FTLD has insidious onset and gradual progression.
177
What aging-related change in the brain increases the risk of delirium induction from anticholinergic drugs?
Loss of neurons in the nucleus basalis of Meynert and septal nuclei.
178
What aging-related change in the brain confers an increased sensitivity to the extrapyramidal effects of antipsychotic drugs?
Loss of pigmented cells in the substantia nigra.
179
What cognitive abnormality, if elicited on mental status
| examination of a patient with depression, would be most suggestive of an underlying comorbid neurocognitive disorder?
Impaired orientation
180
What is an advantage of the Montreal Cognitive Assessment (MoCA) over the Folstein Mini-Mental State Examination (MMSE)?
The MoCA has greater sensitivity for detection of mild
| cognitive impairment.
181
An 88-year-old man with major neurocognitive disorder secondary to probable Parkinson’s disease begins to develop paranoia and agitation over the course of several months. Behavioral interventions are ineffective, and there is concern about caregiver burnout. What would be the first choice for treatment?
An antipsychotic would be the first choice for treatment
| of agitation with psychotic features.
182
What medication may be useful for reducing apathy and
| depression in Alzheimer’s disease?
Methylphenidate
183
What medication can be useful in controlling
| inappropriate sexual behavior?
The antiandrogen medroxyprogesterone is effective in
| reducing sexual drive and sexually aggressive acts both in men who are cognitively intact and in men with brain injury.
184
The mother of a 20-year-old man reports that he has no friends and that he often becomes excessively angry over perceived slights, forever holding grudges. Although the young man is guarded and reluctant to provide information in the interview, he does volunteer that he recently moved out of his apartment because his landlord had unfairly increased his rent, and he states that he intends to file suit against the landlord. You rule out substance use and determine from the mother that these symptoms have been chronic and long-standing, without recent change. What is the most likely personality disorder diagnosis for this patient?
Paranoid personality disorder.
185
Which personality disorder is thought to be a schizophrenia spectrum illness?
Schizotypal personality disorder.
186
What percentage of patients with borderline personality disorder (BPD) commit suicide?
10%.
187
In which of the following personality disorders do individuals often think, “I should”—a phrase that reflects their severe superego and captures their overly high standards, drive, conscientiousness, perfectionism, and rigidity?
Obsessive-compulsive personality disorder.
188
What assessment method is best suited to facilitate accurate diagnosis of personality disorders?
Semistructured interview
189
An individual with which personality disorder is likely to display effusive but labile and shallow range of feelings, with overly impressionistic and hyperbolic descriptions of others at the expense of facts or accurate assessment of the situation?
Histrionic personality disorder
190
In which personality disorder do patients struggle with issues of control, not only of the details of their own life but also of their emotions and of other people?
Obsessive-compulsive personality disorder.
191
A patient describes excessive anxiety in social situations and in intimate relationships. Although she would like to have more friends, she avoids others due to fears of being ridiculed, criticized, rejected, or humiliated. What is the most likely personality disorder diagnosis for this patient?
Avoidant personality disorder.
192
In which of the personality disorders do individuals manifest grandiose self-esteem, fantasies of unlimited potential, a sense of entitlement, and a need for admiration?
Narcissistic personality disorder.
